Request for Re-Instatement of Internet Privileges

To be filled out by Branch Manager:

What was the patron’s first violation of Internet Rules and Regulations? Be precise: __________________________________________________________________________________________________________________________________________________________________________

Date violation entered on patron’s account: ___________________________

What was the patron’s second violation (s) of Internet Rules and Regulations? Be precise:

_________________________________________________________________________________________________________________________________________________________________________

Date violation entered on patron’s account: ___________________________

Additional comments may be made on back of form if necessary.

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(Bottom portion to be filled out by patron requesting re-instatement of Internet privileges)

Patron Name:______________________________ Date: ________________________

Contact number: ___________________________ Library Card Number: __________________

Did you read the Internet Rules and Regulations and sign the Internet Rules and Regulations Internet Agreement form? Yes___ No___

Do you understand why your Internet privileges were suspended? __________________________________________________________________________________________________________________________________________________________________________

Why should your internet privileges be re-instated? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Additional comments may be made on back of form if necessary.